Tube Feeding in US Nursing Home Residents With Advanced Dementia, 2000-2014

Over the last 2 decades, research has failed to demonstrate benefits of tube feeding in patients with advanced dementia.^1,2 Expert opinion and position statements by national organizations increasingly advocate against this practice.³ This study was conducted to describe feeding tube insertion rates from 2000-2014 among US nursing home residents with advanced dementia. Racial disparities were examined because black race has been strongly associated with greater feeding tube use.⁴

The Brown University institutional review board approved this study with a waiver of informed consent. Data were derived from federally mandated Minimum Data Set (MDS) assessments completed quarterly, as required, on all residents in US nursing homes between January 1, 2000, and October 31, 2015. First, residents with the following criteria on an initial MDS assessment completed nearest to April 1 (±60 days) in each year from 2000-2014 were selected: (1) Alzheimer disease or other dementia, (2) severe cognitive impairment,⁵ (3) not dependent for eating, and (4) no feeding tube. Second, residents meeting these criteria who became totally dependent for eating on any MDS assessment completed within 120 days after their initial assessment were identified. Third, the proportion of residents with advanced dementia and recent eating dependency who had a new feeding tube indicated on any MDS assessment during the next 12 months was determined. Poisson regression models were used to estimate the linear time trend of annual changes in insertion rates using all years of data, controlling for age, sex, race (white, black, and other), and stroke. The cumulative change over 14 years was calculated from annual changes, and presented as a comparison of insertion rates between 2000 and 2014 with adjusted risk ratios (ARRs) and 95% CIs. Separate models were generated for white and black residents controlling for age, sex, and stroke. Data were analyzed using SAS (SAS Institute), version 9.4, and Stata (StataCorp), version 14.

Between 2000 and 2014, 71 251 residents with advanced dementia and recent dependence for eating were identified with the following characteristics: mean age, 84 years (SD, 9); women, 76.4%; white, 85.6%; black, 9.5%; and prior stroke, 13.6%. These characteristics were similar across years. The proportion of residents receiving feeding tubes over the next 12 months declined from 11.7% in 2000 to 5.7% in 2014 (ARR, 0.41 [95% CI, 0.38-0.45]) (Table 1 and Table 2). Insertion rates declined between 2000 and 2014 among white residents (8.6% to 3.1%; ARR, 0.37 [95% CI, 0.33-0.41]) and black residents (37.5% to 17.5%; ARR, 0.47 [95% CI, 0.41-0.55]). However, black residents were more likely to get tube fed in 2000 (ARR, 4.4 [95% CI, 4.0-4.7]) and 2014 (ARR, 5.6 [95% CI, 5.0-6.2]) than white residents.

The proportion of US nursing home residents with advanced dementia and eating dependency receiving feeding tubes decreased by approximately 50% between 2000 and 2014. This decline parallels the emergence of research,^1,2 expert opinion, and recommendations by national organizations³ discouraging this practice. Feeding tube use decreased across racial groups, but remained relatively higher among black residents, consistent with prior research.^2,4

This study has limitations. The number of reported feeding tube insertions are specific to the cohort definitions. The actual number of tubes inserted in all US residents with advanced dementia is likely much higher. Moreover, the reported number of residents with advanced dementia and eating problems declined from 2000 to 2014, reflecting the shifting composition of US nursing homes, such that patients with chronic illnesses, including dementia, are being increasingly maintained in the community with greater access to services.⁶ However, given the analyses applied the same definitions to the numerator and denominator in each year, the comparison of annual insertion rates is reasonable. Power was inadequate to examine factors associated with tube feeding use.

To ensure the message from existing evidence and expert recommendations is disseminated and disparities are reduced, fiscal and regulatory policies are needed that discourage tube feeding and promote a palliative approach to feeding problems in patients with advanced dementia.

Correponding Author: Susan L. Mitchell MD, MPH, Hebrew SeniorLife Institute for Aging Research, 1200 Centre St, Boston, MA 02131 (smitchell@hsl.harvard.edu).

Author Contributions: Dr Gozalo and Mr Servadio had full access to all data in the study and take responsibility for the integrity of the data and the accuracy of the data analyses.

Study concept and design: Mitchell, Mor, Gozalo, Teno.

Acquisition, analysis, or interpretation of data: All authors.

Drafting of the manuscript: Mitchell, Gozalo, Teno.

Critical revision of the manuscript for important intellectual content: All authors.

Statistical analysis: Mitchell, Gozalo, Servadio.

Obtained funding: Mitchell, Mor, Teno.

Administrative, technical, or material support: All authors.

Study supervision: Mitchell, Mor, Gozalo.

Conflict of Interest Disclosures: All authors have completed and submitted the ICMJE Form for Disclosure of Potential Conflicts of Interest and none were reported.

Funding/Support: This work was supported by grant NIH-NIA P01AG02729 and NIH-NIA K24AG033640 (Dr Mitchell) from the National Institutes of Health.

Role of the Funder/Sponsor: The National Institutes of Health had no role in the design and conduct of the study; collection, management, analysis, and interpretation of the data; preparation, review, or approval of the manuscript; and decision to submit the manuscript for publication.